Section One of this text focused on the principles of wilderness EMS (WEMS) systems, and how they are organized in overarching topics of medical oversight, equipment, and medicolegal considerations. Section Two followed with the management of wilderness medical conditions where specific injuries and illnesses common to WEMS settings were discussed in depth (ie, management of heat and cold injuries, altitude, and other environmental conditions). The eight chapters that compromise Section Three explore how WEMS actually interfaces with the technical environments commonly associated with wilderness, austere, and resource-limited settings. It will look at specific technical realms where patient care decisions must be balanced with the risk of further injury or illness to both the patient(s) and rescuer(s). Each rescue and patient encounter balances multiple variables that are generally not significant factors in most traditional EMS settings.

Definition—Technical Rescue Interface

Defining the technical rescue interface for the WEMS provider can be a challenging concept if looking for specific or exact fundamentals that must be applied across all technical settings. Each technical rescue interface must be evaluated individually with a set of principles that balance the specifics of the technical situation with the complex medical decision-making and patient care priorities being managed by the WEMS provider. This confluence becomes the technical rescue interface. While each situation is different, there emerge some common themes that persist across each situation. Regardless of the WEMS provider’s medical skill level, each WEMS individual must have a reasonable set of technical skills to keep themselves safe in the setting in which they are performing patient care and ultimately extrication. This interface is a unique facet of WEMS operations.1,2,3,4

Ideally, a WEMS provider is trained and able to enter the technical environment with the appropriate technical skills, but also has the medical knowledge and equipment to begin necessary medical care. This WEMS provider may be a search and rescue (SAR) team member entering an avalanche path to begin resuscitation of a patient, or a ski patroller on the side of a ski slope where a skier just collided with a tree, or a spelunker in the depths of a cave where a patient has taken a serious fall and has an altered mental status. Each of these situations requires medical decision-making to be balanced with the extrication problem and thus bridges the WEMS technical rescue interface.

Search and Rescue Principles: Locate—Access—Treat—Extricate (LATE)

While some challenges in this technical rescue interface are common between different technical realms, unique challenges also exist. Some simplified principles spanning the majority of SAR and other WEMS operations can be summarized by the acronym LATE: Locate—Access—Treat—Extricate. All WEMS operations typically have some degree of each LATE principle in the technical rescue interface; some incidents will require a greater amount of focus and energy based on a specific component (see Box 24.1).

Locate

The Locate portion may prove easy if there is a known location reported, but this may entail a significant part of the SAR event when the location is unknown or not exact. In a traditional EMS system, a 911 call generally gives the location to respond. In the WEMS setting, a SAR team may be called for an overdue party and a search operation will entail. Whole fields of science exist to help frame this type of response with lost person behavior statistics, terrain considerations and rate of travel, techniques for managing search function, etc.5,6,7,8

Access

A common theme that also separates WEMS from traditional EMS is patient Access. Once the patient has been located, the WEMS provider must be able to access that location. They may be located across a raging river, on the side of a cliff, in a cave, or buried in avalanche debris. Figure 24.1A-D give some examples of different access problems that exist. These challenges highlight another paramount difference between traditional EMS, where the ambulance can just “drive up,” have immediate access to the patient, begin patient care, and rapidly initiate transport to a hospital. While some areas of frontier EMS settings have long transport times, the ambulance still has control of the patient compartment temperature and carries all the typical EMS tools.9WEMS takes providers one step further to a remote setting where patient access becomes a significant challenge. Sometimes specialized tools such as helicopters can be utilized, but other times a prolonged terrestrial approach is necessary. These ground-based approaches often require another set of very specialized technical skills and tools (see Chapter 7 for a more complete discussion of WEMS equipment and Chapter 28 for a more complete discussion of WEMS vehicles). Figure 24.2 demonstrates how helicopters provide a useful tool in WEMS settings when a short haul rescue is utilized.

Locate: the first step in any event. The patient must be located before the next steps of a rescue can be taken.

Access: once a patient is located, the WEMS provider must be able to access the location in order to begin patient care.

Treat: this is the main function of the WEMS provider, but in some settings, Extricate may become a higher priority delaying care until the patient arrives at a safe location.

Extricate: the last step of a SAR or other WEMS operation. Removing the patient from the technical environment toward definitive care.

Previous definitions of wilderness medicine have used a 2-hour transport or extrication time to separate WEMS from traditional EMS. But, as previously presented in this text, this definition has several limitations and may not foster best patient care practices. As an example, an urban setting may quickly turn into and WEMS setting in a disaster (ie, Hurricane Katrina in New Orleans, LA); or alternatively when a helicopter extrication mitigates a prolonged ground rescue from hours to a matter of minutes over very complicated terrain. This chapter uses the definition of wilderness medicine and WEMS as outlined in the Introduction and presented in Chapter 1. There are many resources and courses available to increase the proficiency of a WEMS provider in safely gaining access to their patients.1,10

Treat

Initial patient assessment occurs once the provider accesses the patient and can begin to Treat the patient. There are circumstances when the initial assessment can be completed from a distance, over the phone, or possibly in surveillance photographs or videos. Is the patient moving? Are they calling out for help? Or are they motionless or appear to have an unsurvivable injury? This is another facet of remote medical care that presents additional challenges over traditional EMS care. Out-of-hospital providers are taught at virtually all EMS skill levels that the patient should be exposed, or at a minimum just the injured area to perform a focused assessment. In some WEMS settings, this is impractical and can lead to increased problems with hypothermia or other risks with removing personal protective equipment (PPE) such as a climbing harness or helmet. Typically, if there isn’t an immediate life threat, the focused or in-depth assessment may be deferred until the patient is extricated. In such cases, whole-body immobilization in a vacuum mattress (Figure 24.3) will essentially splint everything until the exact injured body area can be determined. This allows for rapid extrication in a dangerous environment and reduces the time the patient and rescuers are exposed to hazards.

Medical decision-making in these technical rescue interface settings is possibly one of the biggest challenges a WEMS provider encounters. This decision-making is undoubtedly the toughest skill to learn and master, as each setting differs and the traditional linear EMS protocols must now be applied or modified while weighing both the benefit and risk of each decision in technical settings. This complexity and added challenge, however, is also why many WEMS providers truly enjoy providing patient care in these types of environments.

FIGURE 24.1. A-D, These images depict a small representation of some access problems, and packaging and movement solutions, that WEMS providers can experience: avalanche, swiftwater, cave/confined space, and cliff/high angle. Note that the backboard in image (B) is being used as a brief patient movement tool and not a longer-term medical immobilization tool. Courtesy of William R. Smith, with permission.

WEMS protocols2,3,4,11,12 must be flexible to allow for this dynamic medical decision-making, and give the WEMS provider the ability to deviate when necessary (see Chapter 4 for additional discussion on protocols and implementation in the WEMS setting). The Wilderness Medical Society has published practice guidelines on many topics that WEMS providers will find useful in patient care in wilderness and austere environments (see Box 24.2). In these technical rescue settings, some of the variables that influence medical decision-making are summarized in Box 24.3.

Direct handover of the patient to a care facility (eg, hospital or clinic), or to another EMS transport service (air or ground) is the last step in the continuum of care in the WEMS setting. The essential details that must be conveyed during this critical step of treatment are covered in more detail in Chapter 6.

Extricate

The last segment of the LATE acronym that helps simplify SAR rescue principles is Extricate. Treatment may continue during this segment but should be concurrent with patient extrication from the technical terrain toward definitive care. In some cases, extrication is simple, but in other situations, it may prove the most difficult part of the operation. As previously mentioned, the circumstances of some environments (Box 24.5 on page [434]) may necessitate the rapid extrication and allow patient care only after the patient has been extricated (eg, avalanche, swiftwater, high angle). This decision is generally made by the lead patient care WEMS provider, and sometimes occurs even before airway, breathing, circulation life threats can be identified.

FIGURE 24.2. Helicopters provide a useful tool in WEMS, although their risk must be balanced to the benefit in the overall operation. Short haul is a rescue technique with the use of a helicopter and one or more persons suspended beneath the helicopter. This can be used for inserting rescuers as well as extricating injured patients from very technical terrain. Courtesy of William R. Smith, with permission.

FIGURE 24.3. The vacuum mattress has become the standard of care for most patient packaging situations in WEMS. Courtesy of William R. Smith and David Bowers Photography, www.davidbowersphotography.com, with permission.

Varying care priorities in this manner during different phases of an operation parallels the military’s phases of care as outlined in the Tactical Combat Casualty Care (TCCC) guidelines: Care Under Fire (CUF), Tactical Field Care (TFC), and Tactical Evacuation Care (TACEVAC).28,29 The TCCC concepts have been applied to more civilian EMS settings in adapted protocols in Tactical Emergency Casualty Care.30 The terminology for these specific care settings is summarized in Table 24.1. In general, many of the patient care principles used in different dangerous situations from TCCC and TECC can be applied to WEMS settings. The specific danger can be swapped from bullets flying in combat settings, to hazmat or active shooter situations in traditional EMS settings, to the side of a cliff in WEMS operations.31

Documentation and Quality Improvement

Like traditional EMS, thorough documentation is also essential in WEMS and should be completed immediately after the call if possible or ideally within 24 hours. Patient care details become difficult to recall after this time frame as other day-to-day priorities will often delay the WEMS provider from submitting the most complete patient care report. Documentation is essential in both supporting the quality improvement (QI) process for patient care improvement and capturing data which can help make future decisions for the WEMS program. Documentation is discussed in more detail in Chapters 30 and 31.

Box 24.3 Variables That Influence Medical Decision-Making

These variables are only a partial set of thoughts that must be considered when a WEMS provider is incorporating medical decision-making into the technical rescue interface.

Changing patient status (improving or deteriorating)—very important to have one dedicated provider [if possible] to monitor and reassess the patient frequently. Also passing this information forward through the succession of care is important. SOAP (Subjective, Objective, Assessment, Plan) notes are often a good format to document and pass onto the next caregiver.

Anticipated medical problems (ie, hypothermia, continued blood loss)—a patient with a head injury and concern for increasing intracranial pressure will require a more rapid and higher risk acceptance for helicopter versus a prolonged ground rescue.

Specific or specialized medical equipment, medication, and supplies available for WEMS operations.

Number of patients—a wilderness MCI adds multiple levels of complexity over a similar traditional EMS MCI.

Extrication time and anticipated time to definitive medical care.

Weather—precluding helicopter options or complicating care plans.

Time of day—nighttime operations generally increase risk, and can have additive effects with hypothermia and other mental/psychological challenges.

Elevation/altitude—Elevation of the scene and altitudes attained during the rescue can affect patient physiology, as well as rescuer health, as well as limit aircraft capabilities.

Acceptable risk/benefit ratio to the team and patient—a definitive discussion point that should be made by the incident commander with input from the safety officer and others, especially the rescuers who will be entering the technical terrain. Some algorithms exist to help flush this out as well as identify mitigation strategies that may be helpful.

Other forms of QI are sometimes used in WEMS operations. Immediate debriefing often occurs after an event and is sometimes called a “hotwash.” This generally occurs in the field before members of SAR teams or other organizations demobilize from the event. It can be performed in different formats and can cover different topics that may have been specific for that event. Generally, the “hotwash” covers how the mission went, were there any safety issues identified and how were they mitigated, what could be done better next time, and what needs to be done to make the team operational for the next event (ie, resupply, stocking, fuel). For larger or more complex WEMS events, often a more formal after action review is held. This is generally facilitated and involves multiple agencies and looks at larger system integration between jurisdictions. Other small intra-team debriefings should occur in order to share lessons learned from each event. This allows the whole team, not just those members who may have only seen a single isolated part of the event or members who may not have even been on scene, to benefit from the experience. This sharing of information from each event can help disseminate best practices to WEMS providers that often have a limited number of calls.

Table 24.1 Recognized Phases of Care As Compared by TCCC and TECC Guidelines, with Common Care Principles Which Can Be Applied to Different WEMS Situations28,29,30,31

Emotional debriefing may also be needed and this should be considered as a separate event from a tactical or operational debriefing. More discussion is included on critical incident stress debriefing and how WEMS providers and teams should be aware of mental health in Chapter 10.

PRINCIPLES OF BASIC TECHNICAL RESCUE

Technical rescue is a necessary component of many WEMS operations. Each environment offers technical challenges and the Access and Extricate problems often require a technical component. Focused individual and team training is a must when dealing with each of these environments or realms. Proficiency must be maintained by initial and ongoing training. If a WEMS provider is not currently proficient, they should not be entering any location where they will be faced with the technical problem. In this situation, it may be necessary that a non-WEMS provider does the extrication to a safe location where the WEMS provider can then begin patient care.

Rescue Group Structure

Rescue groups vary in size and composition depending on multiple variables and requirements. Box 24.4 gives some examples of rescue group structures. The most basic of these possible structures is self-rescue or rescue from companions who are traveling with the patient. In some cases, bystanders can help initiate a rescue, before an organized team can even be dispatched or arrive on scene. These solutions generally allow for the quickest resolution of the event. Groups traveling in very remote areas should consider self- or companion-rescue as their first option as organized rescue may not be available or only be possible with significant delays.

There have also been increases in dedicated groups that are providing rescue services in WEMS realms (eg, SAR teams, ski patrols, cave rescue associations). These can be small focused teams that are trained for extreme technical environments such as a high angle terrain or swiftwater. When an organized rescue occurs, personnel rely on the Incident Command System (ICS) to efficiently manage the incident (ICS implementation in WEMS operations is discussed in more detail in Chapter 3). The Mountain Rescue Association (MRA)* also has many teams that are certified in ICS and other areas so that they can near-seamlessly integrate with other teams in a coordinated response. Other more diverse SAR teams may train in multiple skill areas and can accomplish a rescue in several different types of terrain independently with only organic resources. In some locations, a municipal or rural fire department may have teams that interface with WEMS to augment the overall rescue capability. In complex rescue settings, there may be an overlap between several technical realms and multiple teams must coordinate together, especially in a larger disaster type setting (eg, hurricane, earthquake). Note that natural disaster WEMS care is discussed in more detail in Chapter 18.